Basic Information
| Provider Information | |||||||||
| NPI: | 1689918500 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEORGE | ||||||||
| FirstName: | CURTIS | ||||||||
| MiddleName: | LARCEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1611 E 17TH PL | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741207203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153802756 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11428 E 20TH ST | ||||||||
| Address2: | UNIT A | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741286451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453212049 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2012 | ||||||||
| LastUpdateDate: | 11/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 000000000 | 05 | OK | MEDICAID | 200287120A | 05 | OK | MEDICAID |